Provider Demographics
NPI:1891396636
Name:BARRERA SANTIAGO, JESSICA (RADT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BARRERA SANTIAGO
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13931 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2941
Mailing Address - Country:US
Mailing Address - Phone:310-768-8018
Mailing Address - Fax:310-768-4170
Practice Address - Street 1:13931 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2941
Practice Address - Country:US
Practice Address - Phone:310-768-8018
Practice Address - Fax:310-768-4170
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAR1406831020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator